1. Creating a Culture of Teamwork to Save Lives: What Does it Take? Eduardo Salas, Ph.D. Department of Psychology & Institute of Simulation & Training University of Central Florida esalas@ist.ucf.edu

2. This Morning…  We are taking “a trip”…  Why you should care about teamwork…  What team science tells us about teamwork…  Give you some advice…  What does it take…

3. Going to Mars…2035 …An expert team

4. Long Duration… Confine Environment…

6. This Team Needs To Be…  Reliable, no errors…  Resilient, deal with novel events…  Adaptive, change due to conditions…  Self-correcting, no time for outside intervention…

7. This Team Needs To Be…  Decisive, make quick & robust decisions…  Cohesive, get along…  Safe, errors could cost their lives…  Teamwork, coordinate, cooperate & communicate…

8. And So Does Patient Care!!!!

9. I.What is the State of the Science? What Matters in Teams?

10. What is the State of the Science? How Do We Turn a Team of Experts into an Expert Team?

11. What is the State of the Science?  Theoretically-driven (170+ models!) “Nothing more practical than a good theory.”  It’s a multi-disciplinary field  Explosion of empirical work!  Studying real teams; performing real tasks “Teams in the Wild” Simulations  Experts as participants

12. What is the State of the Science?  Hundreds of teams! Aviation Healthcare Military Corporate world  Teams defined Task interdependency Distributed expertise Hierarchical organized Member Fluidity

13. What is Teamwork?  It is the actions, events and behaviors, cognition, feelings taken to accomplish a team goal.  It is about… …taskwork skills (i.e., own task). …teamwork skills (i.e., how to work together). …building and maintaining both.

14. What Matters… The 7 C’s of Teamwork…

15. COMMUNICATIONCOMMUNICATION TEAMWORK Organizational & Individual Outcomes

16. Cooperation…  Attitudes & Beliefs: Team Orientation Collective Efficacy Mutual Trust Openness to Experience  Good Teams… Develop collective efficacy Have strong team orientation

17. Coordination…  Behavioral Mechanisms: Mutual Performance Monitoring Back-up Behavior/Supportive Adaptability/ Flexibility  Good Teams… Self-correct Employ huddle, debriefs

18. Communication…  Information exchange protocols: Close-loop communication Precise, Timely, Clarity Appropriate terminology  Good Teams… Share unique information

19. Cognition…  Shared understanding: Roles & Responsibilities Knowledge of team mission; Objectives, Norms, & Resources Familiarity with Teammates  Good Teams… Have clear roles Team norms are clear

20. Coaching…  Leadership: Team Leadership  Promotes teamwork  Cares about team members  Sets ground rules  Good Teams… Have coaches Set expectations Clarify roles

21. Conflict…  Conflict resolution strategies: Interpersonal skills Psychological safety  Good Teams… Deal with conflict, confront it Coaches create psychological safety

22. Conditions…  Supportive context Good performance recognized & reinforced Access to resources Information needed available  Policies, procedures & incentives aligns  Leadership sends “signals” that teamwork matters

23. II. Ten Characteristics of Effective Teams…

24. Ten characteristics of effective teams… 1. Clear roles & responsibilities …have members who understand each others’ roles and how they fit together. 2. Compelling purpose – goal, vision …have a clear common purpose. …energized by their shared mission. …can evaluate current status in terms of a destination.

25. Ten characteristics of effective teams… 3. Team coach (leader) – promotes, develops, reinforces …leaders that directly intervene to enact teamwork processes. …have team members who believe the leaders care about them. …provide situation updates. …set expectations. …self-correct first. …clarify roles. …solicit ideas and observations from team members. …seek out opportunities to reinforce effective teamwork.

26. Ten characteristics of effective teams… 4. Mutual trust – familiarity …manage conflict well—team members confront each other effectively. …have a strong sense of team orientation. …trust other team members’ “intentions”. …strongly believe in the team’s collective capability to succeed. …develop collective efficacy.

27. Ten characteristics of effective teams… 5. Team norms – clear, known & appropriate …what is acceptable “around here”. 6. ​ Shared understanding of task, mission & goals – hold shared mental model …have members who anticipate each other. …can coordinate without overt communication.

28. Ten characteristics of effective teams… 7. ​ Self-correct – huddles, debriefs …regularly provide feedback to each other, both individually and as a team (“de-brief”). …establish and revise team goals and plans. …differentiate between higher and lower priorities. …have mechanisms for anticipating and reviewing issues/problems of members. …periodically diagnose team "effectiveness”, including its results, its processes, and its vitality (morale, retention, energy).

29. Ten characteristics of effective teams… 8. Set expectations (and are managed) – clear, understood 9. Shared unique information – efficient information protocols …huddles, debriefs can help. 10. ​ Launched correctly Kick-off meeting

30. III. Seven Pieces of Advice…

31. Some Advice… 1. Ensure all team members are trained on team-based KSA’s…around six of the C’s… Team training ≠ Team building Information, demonstration, practice & feedback, key elements Scenario carefully crafted Event-based approach

32. Does Team Training Work?

33. YES!!!

34. Team Training Works!  Compared with current training, enhanced training resulted in (see Cannon-Bowers & Salas, 1998 1 ) : 45% improvement in Mission Performance. 33% improvement in Tactical Decision Making Performance. 25% improvement in Communication Efficiency. 10-34% improvement in Team Coordination.  In the aviation environment (Salas et al., 1999 2 ) : 6-20% improvement in Teamwork Behaviors. 1 Cannon-Bowers, J. A., & Salas, E. 1998 2 Salas, E. et al 1999

35. Does Team Training Work?  Team training significantly improves team 3 : Cognition (ρ =.42)  Shared mental models Behavioral process (ρ =.44)  Communication, coordination, collaboration Affect (ρ =.35)  Mutual trust, collective efficacy Performance outcomes (ρ =.37)  Task outcomes, satisfaction, viability 3 Salas et al., 2008

36. Does Medical Team Training Impact Clinical Outcomes?

37. State of the Science of Medical Team Training…  106 Independent Samples, 93 studies were included in the meta-analysis Military clinicians-3 Nonmilitary clinicians-79 Students-20 Mix-4  Most team training programs were developed in house (38.68%)  Most teams trained are interprofessional (72.64%) but interdisciplinary teams were minority (26.42%)  Communication was the competency most commonly trained (31.66%)

38. What Did We Find? OutcomeK1K1 N2N2 Corrected d RM 3 Variance accounted for Overall10619700.65*9.5% Reactions3660.65*9.6% Learning585489.83*14.67% Behaviors4777270.58*7.29% Organizational Outcomes 2955910.30*2.19% Patient Outcomes1693500.43*4.42% 1.K is the number of effect studies analyzed for this outcome 2.N is the number of individuals evaluated in this outcome 3.Corrected d Rm is the corrected effect size estimate *Statistically significant; confidence interval excludes zero

39. What Do the Data Mean?  Team training improves overall outcomes by 9.5%  Team training is well-liked and perceived as useful 9.5%.  Team Training accounts for 14.67% of learning  7.29% of improvement of on-the-job performance - This includes both task and team performance  Team training accounts for 2.19% of improvement in organizational outcomes (e.g., culture, turnover, financial)  Team training accounts for 4.42% of improvement in patient outcomes (e.g., infection, mortality, complications)

40. Some Advice… 2. ​ Teach how to Debrief and Huddle!- Simple, Powerful, & Underutilized What worked? What can be improved? Focus on as many C’s as possible. Debriefing works! (Tannenbaum & Cerasoli, 2012)  25% Performance improvement

41. Some Advice… 3. Use Simulation! Games, role plays Accelerates expertise Embedded instructional features

42. Some Advice… 4. Develop team coaches, leaders… 5. ​ Measure & Reinforce teamwork! 6. ​​ For sustainability…create conditions needed… …continuous process …seek supervisory support …not an event, journey …physicians must engage …CFO/CEO/CMO must see value, business case

43. Some Advice… 7. See if you can use this statement: “Am Dr. ____, I am a good surgeon but I am vulnerable to error so you are here to help me take care of this patient– we are a team.”

44. IV. What Does It Take…

45. Success Factors 1. ​ Leverage pre-existing team training programs (e.g., TeamSTEPPS, CRM)…Adapt to needs! 2. Need to understand the coordination demands in your units…Not all teams created equal…Task interdependence matters… 3. Need to focus on teamwork-related KSAs… 4. ​ Prepare the organization, supervisors, leaders and trainees for team training…

46. Success Factors 5. Create conditions - A support system that facilitates the application of the trained skills back on the job… …Supervisory support… …Opportunity to practice… …Providing tools for teamwork & collaboration -- checklists, debriefs, huddles, teamwork aids… … Team coaching…

47. Success Factors 6. …An organizational commitment (CEO, CFO, CMO)– leadership support to do things differently… Long-term culture change efforts… Resources allocated… 7. …A cadre of organizational mechanisms to promote & reinforce teamwork…creating the conditions for sustainability… Measure & reinforce teamwork… A journey, not an event…

48. Success Factors 8. …Continuous learning & educating… Support IPE…Start early… 9. …Discipline in using performance support tools – debriefing, huddles, simulation… 10. …Physicians on-board, supporting…champions…

49. V. Final Thoughts…

50. Final Thoughts…  Effective teamwork is the foundation for effective patient care.  Teams can learn to be more effective and save lives. The science of teamwork  Remember the 7 C’s of teamwork and the patterns of effective teams.

52. How Can I Help?